Anesthesia E-ssential July 30, 2014

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Anesthesia E-ssential

July 30, 2014

Vital Signs

Coming Soon...

Roll out of the AANA’s most comprehensive, national public relations campaign to date is right around the corner. Announced at the April meeting of the AANA Board of Directors, this creative, multi-faceted campaign will enable the AANA, state associations, and individual members to promote the value of CRNAs—on an ongoing basis—to key audiences that have the greatest impact on the nurse anesthesia profession. Developed with the support of an internationally renowned PR firm, the campaign will feature a compelling website, fact-based messaging, robust social media activities, CRNA stories, toolkits, infographics, and more. For a peek at what’s to come, check out the AANA’s first infographic titled Anesthesia and the Changing Healthcare Landscape: CRNAs’ Valuable Role, which premiered in February 2014.

Earlier this year, responses to the Member Needs Assessment Survey confirmed that CRNAs want their professional association to tell the world who you are. Rest assured, the AANA heard you loud and clear! This new PR campaign will deliver the message, time and again, that CRNAs are highly educated and skilled professionals who ensure patients access to safe, cost-effective anesthesia care and other essential healthcare services…24/7…all across the United States.

Watch for more information coming soon on the AANA website, in your AANA publications, and in your email, and gear up to help the AANA get the word out about the value of CRNAs.

Healthcare Headlines is for informational purposes, and its content should not be interpreted as endorsements, standards of care, or position statements of the American Association of Nurse Anesthetists.

Inside the Association

FDA Approves Ryanodex® for the Treatment of Malignant Hyperthermia

The FDA has approved Eagle Pharmaceuticals’ Ryanodex® (dantrolene sodium) for the treatment of malignant hyperthermia (MH). Ryanodex is available in single-use vials containing 250mg of dantrolene sodium in lyophilized powder form. It is formulated for rapid reconstitution and administration in less than one minute to patients in MH crisis. Ryanodex will become available to order in August and will begin shipping shortly thereafter. More information can be found in the press release.

Recertification Summit Webinar Video Available Online

The video of the Recertification Summit and webinar held on June 27-28, 2014, is now available online. The summit presented information about the Continued Professional Certification (CPC) program and answered audience questions. Click here for more information (member login and password required). If you have questions as you view the videos, email your questions to MemberCPCcomments@aana.com.

Partial CE Credit Available to CE Applicants

The AANA Continuing Education Department has made a change to the rule regarding CE credit hour increments. Previously, one continuing education credit was awarded per 60 minutes of eligible content, and partial credits were not awarded. Effective with Prior Approval and Nonprior Approval applications received in the AANA CE Department Aug. 1, 2014, and after, partial credits in increments of 0.25 will be accepted. When submitting CE application materials be sure to use the updated documents that address this change on www.aana.com.

Essential New Book from AANA: The Chemistry and Physics of Drugs Used in Anesthesia

Now available through the AANA Bookstore, The Chemistry and Physics of Drugs Used in Anesthesia, by Cynthia Dowd, PhD, and Lemont Kier, PhD, adds an in-depth exploration of physics to significantly expand and update their previous work, The Chemistry of Drugs for Nurse Anesthetists, making this new text even more integral to the practicing CRNA and to the education of student registered nurse anesthetists. Educators: This book has useful new features including a glossary that explains key content areas, a more comprehensive index, and discussion questions at the end of each chapter to facilitate small group engagement. Students: This book is priced with you in mind and includes hundreds of helpful illustrations to facilitate ease of learning. The Chemistry and Physics of Drugs Used in Anesthesia provides the solid foundation for every nurse anesthetist’s practice. The 411-page, softbound book sells for $67.50.

Office-Based Anesthesia Webinar:

Tuesday, August 12, 2014 (7 p.m. CDT)

State leaders and other interested members are invited to register for a webinar concerning office-based anesthesia. This webinar will cover office-based anesthesia issues and will review a new toolkit of resources and information developed by the AANA Government Relations Committee and State Government Affairs Division. Click here to register!

CRNA Volunteering Opportunity with Seed Global Health

Seed Global Health is looking for CRNA volunteers to serve as health educators in Malawi, Tanzania, and Uganda. Participants make a one-year commitment as Peace Corps Response volunteers and receive monthly living stipends, transportation to and from their country of service, comprehensive medical care, vacation days, and readjustment allowance. In addition, through loan and debt repayment of up to $30,000, Seed Global Health reduces the barriers for the highest-qualified candidates to volunteer for the program. Learn more about the program and the application process here or contact info@seedglobalhealth.org.

New and Improved Member Benefit Program Introduced

AANA is pleased to announce a new and improved member benefit program. The AANA Member Advantage Program brings you new and valuable products and services while maintaining the brands you currently enjoy. We have enhanced the program with these goals in mind:

Member Value - We put our members first. We listen to your feedback and seek to deliver the products and services you want and need.

Industry excellence - We offer you companies and brands that are competitive in the marketplace.

Customer service - Our partners deliver the high-quality customer service you expect and deserve.

Two new services now available are:

Darien Rowayton Bank - Members can now consolidate private and federal loans together into one loan with competitive interest rates.

Wyndham Hotels - The Wyndham collection includes 12 hotel brands worldwide and provides members up to a 20 percent discount on the best available room rate.

Renew Your Membership Online: It's Easy!

Membership Dues Deadline: October 31, 2014

Renewing your AANA membership for the fiscal year Sept. 1, 2014, through Aug. 31, 2015, is easy and convenient. Just click here (AANA member login and password required) and complete the online process using your credit card. You can also renew your membership using the paper forms sent to you through the mail. See the AANA website for further information about membership and its benefits.

Orlando – The Stars Come Out Again

This fabulous and fun event will take place on Sunday, Sept. 14, 2014, and will feature talented CRNAs and SRNAs competing for fabulous prizes. There will also be dancing, dinner, drinks and a DJ. Sponsorships are available and include tickets and recognition. If you’re interested in performing, Talent Applications are due July 31 – so submit your application today. Please visit the Orlando – The Stars Come Out Again webpage to learn more. Questions? Contact Luanne Irvin, AANA Foundation Development Officer, at (847) 655-1173 or lirvin@aana.com.

17th Annual Golf Tournament at Hawk’s Landing Golf Club

Plan to tee off on Friday, Sept. 12 at 1:30 p.m. at Hawk’s Landing Golf Club at Orlando World Center Marriott Resort. Click here to visit the golf tournament webpage for more details including information on club rental, sponsorships, contests, and photos from past Foundation golf tournaments.

State Government Affairs

State Government Affairs Webinar on Action Coalitions – Available Now!

Please visit the AANA State Government Affairs page for a newly released webinar on Action Coalitions. This program, featuring Pauleen Consebido, CRNA, MS, APRN, Nancy Gondringer, CRNA, MA, and Lori Schirle, CRNA, MSN, is brought to you by the AANA Government Relations Committee. The webinar provides information on the history of action coalitions, including recommendations of the Institute of Medicine (IOM) Future of Nursing Report, and discusses coalition work and examples of CRNA involvement in action coalitions. Take advantage of this opportunity to learn about valuable information and resources important to CRNAs and state nurse anesthetist associations.

Save the Date: Lobbyist Track at the Fall Leadership Academy

Nov. 7-9, 2014, in Rosemont, Ill.

New this year, the Fall Leadership Academy will feature a Lobbyist Track in conjunction with the Government Relations (GR) Track. The goal of this track is to enhance opportunities for education and networking for state associations’ lobbyists and to educate them about issues specific to CRNAs to help advance the practice of nurse anesthesia at the state level. For more information, please contact Anna Polyak, RN, JD, senior director, State Government Affairs at apolyak@aana.com.

If You Can’t Be There, You Can Still Be There!

If you absolutely cannot attend the Nurse Anesthesia Annual Congress in Orlando in person, you don’t have to miss out completely. The AANA Congress Daily will be arriving in every member’s email on Sunday, Monday, and Tuesday during the meeting, plus you’ll receive two Congress newswires during the two weeks leading up to the meeting. The Daily is filled with news and information about and from the meeting—stuff you won’t want to miss. Coming soon to an e-mailbox near you!

A Medicare proposal for its 2015 physician fee schedule includes several provisions important to CRNAs, on issues including reimbursement for GI anesthesia services and certain pain management services, and incentives for quality reporting, for which AANA is preparing comments in response by a Sept. 2, 2014, deadline. Though it did not issue the critical anesthesia or physician fee schedule conversion factors affecting all 2015 Part B payments and plans linked to Part B (such as TRICARE), the Medicare agency:

As AANA has recommended, proposes to revert back to the previous higher relative values for epidural injections (CPT codes 62310, 62311, 62318 and 62319) than were cited in the CY 2014 Physician Fee Schedule interim final rule. CMS also proposes to include these CPT codes on the potentially misvalued code list to obtain information to support their valuation with the image guidance included;

As AANA has recommended, revises the definition of “colorectal cancer screening tests” to include anesthesia that is separately furnished in conjunction with screening colonoscopies. If this proposal is adopted, there would be no beneficiary coinsurance or deductible applied to anesthesia associated with screening colonoscopy even when the anesthesia is furnished by an anesthesia professional, such as a CRNA or an anesthesiologist;

As AANA has recommended, seeks approaches to valuing certain procedures, such as endoscopic procedures, that would allow Medicare to pay accurately for moderate sedation when it is furnished while avoiding potential duplicative payments when separate anesthesia is furnished and billed;

Proposes to adjust the anesthesia malpractice (MP) relative value unit (RVU) update in the CY 2016 Physician Fee Schedule Proposed Rule and seeks comments in this rule about how best to do so;

Expresses a concern about operational and program integrity issues associated with locum tenens (substitute physicians) and seeks to better understand current industry practices;

Proposes to make all 2015 Physician Quality Reporting System (PQRS) measures available for public reporting at the individual eligible professional level on CMS’s Physician Compare website for data collected in 2015. Also proposes that non-PQRS measures developed by medical societies would also be made available for public reporting on the Physician Compare website, and to remove the perioperative measures group from PQRS because the performance rate is approaching 100 percent; and,

Proposes to apply the Value-Based Payment modifier (VM) include eligible professionals such as CRNAs starting in CY 2017. The VM provides for differential payment to an eligible professional or a group of eligible professionals under the Medicare Physician Fee Schedule based upon the quality of care furnished compared to cost during a performance period.

According to the proposed rule, allowed 2015 charges for anesthesiology are $1.979 billion, a decrease of 1 percent allowing for the impacts of adjusting RVUs to match revised Medicare economic index weights. For nurse anesthetist / anesthesiologist assistant, allowed 2015 charges are $1.177 billion, a zero percent increase allowing for impacts of similar adjustments. (Though the overall allowed charge for anesthesiology is different than for CRNAs, they are both subject to the same anesthesia conversion factors.) Total physician fee schedule allowed charges are $87.375 billion. Current relief from “sustainable growth rate” (SGR) cuts to Medicare anesthesia and physician payment extends through the end of March 2015.

Veterans Healthcare Remains Under Microscope in Washington; CRNAs and Other APRNs Promote Benefits of Their Care

Veterans health benefits remain under the microscope in Washington, with the approval of a new Veterans Affairs secretary and legislation expanding Veterans access to care in the private marketplace dominating the end of Congress’ summer session. Because Veterans access to high-quality, cost-effective care remains a significant concern, AANA and other advanced practice nursing organizations continue promoting the benefits of APRN care as a common-sense solution on Capitol Hill and in the Administration.

In a unanimous vote July 23, the Senate Veterans Affairs Committee approved the President’s nomination of Robert McDonald to serve as Secretary of Veterans Affairs, an action supported by AANA and APRN organizations. Of the President’s nomination, AANA President Dennis Bless, CRNA, MS, called McDonald “an individual with exceptional private sector experience and a proven leader that has demonstrated his ability to manage and deliver results. His experiences as Captain in the U.S. Army, President and Chief Executive of Procter & Gamble, have prepared him well to lead the VA through this demanding time.” The next step is for the full Senate to vote on his confirmation.

Meanwhile, at press time House and Senate negotiators were announcing agreement on legislation intended to reform the Veterans Administration and expand Veterans access to healthcare. Of interest to CRNAs, the bill boosts funding for hiring nurses and physicians, and helps to fund some Veterans healthcare in the private marketplace. AANA continues working with APRN organizations and the Veterans Administration to promote recognition of CRNAs and other APRNs as full practice providers.

With Leadership Changes in Congress, California CRNA Reaches Right Place at Right Time

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Maricel Isidro-Reighard, CRNA, DNP, the California Association of Nurse Anesthetists Federal Political Director, visited her congressman, Rep. Kevin McCarthy (R-CA), at AANA Mid-Year Assembly, just weeks before his colleagues elected him House Majority Leader.​

All around the country, CRNAs are working through their Federal Political Directors (FPD) and key contacts to build relationships with their members of Congress and to educate them about the value and role of CRNAs in ensuring access to quality healthcare. Sometimes a CRNA is in the right place at the right time to build and strengthen a critical relationship in a time of leadership change in Washington.

The Virginia Republican primary election in June deposing powerful House Majority Leader Eric Cantor (R-VA) set into motion an election among House Republicans to fill the vacancy, which they did by advancing Rep. Kevin McCarthy (R-CA) into the Majority Leader slot effective Aug. 1. Weeks before, at AANA Mid-Year Assembly, Maricel Isidro-Reighard, CRNA, DNP, the FPD of the California Association of Nurse Anesthetists, visited Rep. McCarthy in his U.S. Capitol office.

If you’re active in the AANA, the next CRNA in the right place at the right time may be you!

Calling AANA Members Cost CRNA-PAC More than Expected, so Your Support for CRNA-PAC Is Needed Now

Because new Federal Communications Commission (FCC) regulations significantly increased the cost of reaching AANA members via cell phone, and because more and more AANA members have abandoned land-line phones, income for the CRNA-PAC’s 2014 fundraising campaign which relies in part on such phone calls is coming up short of projections.

With the November elections less than 100 days away, the shortfall can be corrected only through the actions of AANA members – especially by contributing online via www.crna-pac.com (AANA member login and password required), or as part of the AANA 2015 dues checkoff notice.

Supported 100 percent by members’ voluntary contributions and not by dues, the CRNA-PAC is governed by CRNAs to strengthen CRNAs’ voice in Washington, to elect CRNA-friendly members of Congress, and to help further educate lawmakers influential on CRNA issues. Because of the voluntary contributions of AANA members to CRNA-PAC, AANA Federal Government Affairs staff team members and AANA members around the country make contacts with lawmakers and candidates some 350 times per year, both Democrats and Republicans, building relationships that make a difference.

FEC-Required Legal Notification for CRNA-PAC

Gifts to political action committees are not tax deductible. Contributions to CRNA-PAC are for political purposes. All contributions to CRNA-PAC are voluntary. You may refuse to contribute without reprisal. The guidelines are merely suggestions. You are free to contribute more or less than the guidelines suggest and the association will not favor or disadvantage you by reason of the amount contributed or the decision not to contribute. Federal law requires CRNA-PAC to use its best efforts to collect and report the name, mailing address, occupation, and the name of the employer of individuals whose contributions exceed $200 in a calendar year. Each contributor must be a US Citizen.

Opioid Use Does Not Impair Reverse Shoulder Arthroplasty SuccessResearchers in Texas say patients who take painkillers before reverse shoulder arthroplasty are just as likely to experience successful outcomes as those who do not. Their study involved 68 patients, 32 of whom had previously used opioids to treat their shoulder pain. At baseline, those in the painkiller group scored markedly worse on measures of shoulder function and range of motion than those in the non-opioid cohort. While the non-opioid patients continued to outperform in terms of scores following surgery, the improvements seen in both groups were of similar magnitude, according to the researchers. "Patients with a history of preoperative opioid use can obtain significant preoperative-to-postoperative improvements," the team concluded, "yet, they should not be expected to reach the same peak outcome scores as patients without a history of preoperative opioid use."

Children Undergoing Surgery Need Special Care With AnesthesiaChildren who receive anesthesia require different, special care compared to adults. Kids usually receive a sedative, such as a liquid form of midazolam, to ease stress and induce sedation before surgery, says Dr. Lydia Jorge-Reynolds, assistant professor of pediatric anesthesia at the University of Miami at Jackson Memorial Hospital. Adults usually receive pre-dosed anesthesia based on an ideal body weight, but children receive doses based on their actual weight, said Dr. Sandra Kaufmann, chief of pediatric anesthesia at Joe DiMaggio Children's Hospital. Unlike adults, children under age seven do not really understand levels of pain, and they cannot tell the difference between a little or a lot of pain. While children can respond negatively quicker while under anesthesia, they also can be awakened quicker. They are also more likely to have undiagnosed diseases that can complicate the anesthesia or the procedure, including a drug allergy or malignant hyperthermia, an extreme rise in body temperature following general anesthesia.

Naloxegol Shows Efficacy Against Multiple Symptoms of Opioid-Induced Constipation in Phase III TrialsOpioid-induced constipation (OIC), which affects 40 percent to 60 percent of those prescribed narcotic painkillers, can be so severe that patients simply stop taking the medication. Researchers say, however, there is evidence that the opioid receptor antagonist naloxegol safely and effectively alleviates the symptoms. In the KODIAC-04 and KODIAC-05 randomized trials involving roughly 700 participants already taking oral morphine, some received 12 weeks of treatment with naloxegol at one of two doses while others received a placebo. In both studies, the higher dose of naloxegol improved the primary outcome—frequency of bowel movements—and also produced therapeutic gains of 10 percent to 15 percent in other symptoms of OIC, such as straining and hard stool. "To conclude, naloxegol was efficacious over 12 weeks of treatment for noncancer pain patients with OIC," said lead researcher William Chey, MD, of the University of Michigan Health System. "Efficacy was demonstrated with the 25-mg dose in both of these larger, randomized Phase III studies."

Nerve Blocks Linked to Improved Tissue OxygenationU.S. and Austrian researchers paired up for a small pilot study on the impact of nerve blocks on muscle oxygenation during joint replacement surgery. In comparing 10 patients who underwent total knee arthroplasty under spinal-epidural anesthesia at the Hospital for Special Surgery in New York, the team observed an overall reduction in tissue oxygenation. However, this reduction—likely caused by blood loss and other intraoperative events—was greater in the arms than in the legs, suggesting that the lower extremities may have benefited from regional sympatholysis in the areas affected by neuroaxial blockade. Improved tissue oxygenation in the surgical extremity could possibly lead to better healing of the wound and less risk of wound infection, but more research is needed.

Ketamine Can Act as a Wonder Drug in ER: ResearchersThe drug ketamine is not being utilized to its full potential in emergency rooms (ERs), Canadian researchers report in the Annals of Emergency Medicine. While many healthcare providers have balked at using the drug for intubation out of fear that it increases intracranial pressure, studies show no difference in pressure whether ketamine, fentanyl, sufentanil, or other induction agents are used. The latest findings indicate that ketamine can be used as a painkiller, sedative, or amnesia-inducing agent in the ER and that it is a better choice than etomidate, which has come under scrutiny for its potential adverse effects. Lead researcher Corinne Hohl, MD, and colleagues at Vancouver General Hospital believe that given the uncertainty surrounding etomidate, ERs should use ketamine "routinely" for patients with life-threatening infections and "regularly" for patients who are brought in unconscious. They also say a large, randomized controlled study is needed. "In the meantime," according to Hohl, "our review suggests what many emergency physicians already believe is true: Ketamine is safe and incredibly useful in critically ill patients who require rapid intubation."

From "Ketamine Can Act as a Wonder Drug in ER: Researchers" Nature World News (07/24/2014)

Study Reveals Link Between Controlling Childbirth Pain and Lower Risk of Postpartum DepressionNew research suggests that women who undergo epidural anesthesia during vaginal delivery are much less likely to suffer from postpartum depression than those who do not. Reporting in Anesthesia & Analgesia, the investigators say patients who declined pain relief had a 35 percent increased risk of developing clinical depression six weeks after giving birth, compared to just 14 percent of women who opted for epidurals to control their labor pain. Additionally, breast feeding was more common in the epidural group. "It's a huge omission that there has been almost nothing in postpartum depression research about pain during labor and delivery and postpartum depression," according to Northwestern University researcher Katherine Wisner, MD. "There is a well-known relationship between acute and chronic pain and depression."

General Anesthesia Linked to Mortality in Stroke PatientsWhile earlier research has suggested that better clinical and radiographic outcomes can be expected when general anesthesia is used on stroke patients instead of local anesthesia, three recent studies refute this finding. The new evidence indicates that patients with acute ischemic stroke who undergo endovascular intervention therapy, which can be performed either under moderate conscious sedation or under general anesthesia, face a greater risk of mortality with general anesthesia. Neurologic outcomes also appear to be worse with general anesthesia. The choice of anesthesia approach does not, however, appear to affect patients' functional independence at discharge, according to investigators at SUNY Upstate Medical University. "This study is very similar to a couple other retrospective studies that showed that general anesthesia did predict worse outcomes," said Kathryn Rosenblatt, MD, an anesthesiology resident at the university. "We also saw that if you survive the hospitalization, your functional independence level at discharge was no different between general anesthesia and conscious sedation," although the reason for this remains unclear.

No Effect of Acetaminophen in Acute Low Back PainWhile clinical guidelines around the world recommend paracetamol (acetaminophen) as the first-choice prescribed analgesic for acute low-back pain, new research suggests that it actually does nothing to accelerate recovery. The Paracetamol for Low-Back Pain Study, better known as PACE, randomized 1652 patients with the condition to take the drug three times per day, for a combined dose of 3990 mg; take it only as needed, up to 4000 mg per day; or take a placebo. The results indicated that neither regular nor as-needed paracetamol had an impact on recovery from low-back pain, the primary end point. Secondary outcomes—such as pain intensity, disability, global symptom change, quality of sleep, and quality of life—also were no better with paracetamol than without. "The results suggest we need to reconsider the universal recommendation to provide paracetamol as a first-line treatment for low-back pain," remarked lead author Christopher Williams, PhD, from the University of Sydney in Australia. The findings were published this month in The Lancet.

FDA Approves New Opioid Pain Reliever Designed to Be Hard to AbuseA new version of oxycodone that delivers the pain relief, but not the "high" of other forms of the drug, has been approved by the Food and Drug Administration (FDA). The hope is that pairing the narcotic painkiller with naloxone, which blocks the euphoria that users feel, will make Targiniq ER less tempting to prescription drug abusers. While the FDA acknowledges that the new formulation is not likely to completely block misuse of the drug, it does expect to see some reduction in abuse. "The FDA is committed to combating the misuse and abuse of all opioids," said Sharon Hertz, deputy director of the agency's Division of Anesthesia, Analgesia and Addiction Products. "The development of opioids that are harder to abuse is needed in order to help address the public health crisis of prescription drug abuse in the U.S." The product is not without its nay-sayers, however. The naloxone only becomes active when the pill is crushed; but most abusers swallow the medication whole. Moreover, adds Physicians for Responsible Opioid Prescribing President Dr. Andrew Kolodny, doctors who view the drug as safe may start to prescribe Targiniq as a first solution instead of looking at other options.

From "FDA Approves New Opioid Pain Reliever Designed to Be Hard to Abuse" Los Angeles Times (07/23/14) Girion, Lisa

Wake Up: Activating Dopamine Pathway in Brain Helps Doctors Arouse Patients From General AnesthesiaThe sooner that patients emerge from general anesthesia, the better; however, there is no treatment to effectively reverse the temporary confusion, heavy-headedness, and other effects that patients experience while under. Instead, the drugs must simply be allowed to wear off. There is hope, though, based on the theory that certain drugs may activate arousal pathways in the brain to promote emergence from anesthesia. To explore this, researchers performed electrical stimulation on lab rats that were anesthetized with isoflurane or propofol. They targeted two areas key to the formation of dopamine pathways: the ventral tegmental area (VTA), which is tied to cognition and motivation, and the substantia nigra, which controls movement. Investigators discovered that electrical stimulation of the VTA returned the animals to consciousness. "Because dopamine releasing cells in the VTA are important for cognition, we may be able to use drugs that act on this region not only to induce consciousness in anesthetized patients, but to potentially treat common postoperative emergence-related problems such as delirium and restore cognitive function," said lead study author Dr. Ken Solt, Harvard Medical School assistant professor of anesthesia. The research is to be published in the August issue of Anesthesiology.

SPH Study: Increased Risk of Birth Defects From Opioid UseNew studies indicate that opioids like codeine, hydrocodone, and oxycodone are being prescribed to pregnant women more than ever before. Expecting mothers are taking the narcotic painkillers to alleviate discomfort triggered by weight gain, back and abdominal pain, pelvic floor dysfunction, and other problems. The increased use of the drugs is disturbing, however, to those who believe opioids can raise the risk of birth defects in babies. Research conducted by Martha Werler, an epidemiology professor at Boston University's School of Public Health, has demonstrated a link between use of opioids in the first trimester and neural tube defects—one of the most common types of birth defect. Her 2013 research, which she says is the third study to discover this correlation, found that women who gave birth to infants with neural tube defects reported greater opioid use in the early months of their pregnancy (3.9 percent) compared to women who had children without the condition (1.6 percent). "Our study suggests that women of childbearing age—not just those who are pregnant—should refrain from opioid use because neural tube defects develop in the first weeks of gestation, when pregnancy may not be recognized," Werler commented.